Introduction
Colorectal cancer is the second most common cause of death from neoplastic disease in men and third in women of all ages. Globally, life expectancy is increasing, and consequently, an ...increasing number of operations are being performed on more elderly patients with the trend set to continue.
Elderly patients are more likely to have cardiovascular and pulmonary comorbidities that are associated with increased peri-operative risk. They further tend to present with more locally advanced disease, more likely to obstruct or have disseminated disease.
The aim of this review was to investigate the feasibility of laparoscopic colorectal resection in very elderly patients, and whether there are benefits over open surgery for colorectal cancer.
Methods
A systematic literature search was performed on Medline, Pubmed, Embase and Google Scholar. All comparative studies evaluating patients undergoing laparoscopic versus open surgery for colorectal cancer in the patients population over 85 were included.
The primary outcomes were 30-day mortality and 30-day overall morbidity. Secondary outcomes were operating time, time to oral diet, number of retrieved lymph nodes, blood loss and 5-year survival.
Results
The search provided 1507 citations. Sixty-nine articles were retrieved for full text analysis, and only six retrospective studies met the inclusion criteria. Overall mortality for elective laparoscopic resection was 2.92% and morbidity 23%. No single study showed a significant difference between laparoscopic and open surgery for morbidity or mortality, but pooled data analysis demonstrated reduced morbidity in the laparoscopic group (
p
= 0.032). Patients undergoing laparoscopic surgery are more likely to have a shorter hospital stay and a shorter time to oral diet.
Conclusion
Elective laparoscopic resection for colorectal cancer in the over 85 age group is feasible and safe and offers similar advantages over open surgery to those demonstrated in patients of younger ages.
The robotic approach is rapidly gaining momentum in colorectal surgery. Its benefits in pelvic surgery have been extensively discussed and are well established amongst those who perform minimally ...invasive surgery. However, the same cannot be said for the robotic approach for colonic resection, where its role is still debated. Here we aim to provide an extensive debate between selective and absolute use of the robotic approach for colonic resection by combining the thoughts of experts in the field of robotic and minimally invasive colorectal surgery, dissecting all key aspects for a critical view on this exciting new paradigm in colorectal surgery.
Background
Transanal minimally invasive surgery (TAMIS) is an advanced technique for excision of early rectal cancers. Robotic TAMIS (r-TAMIS) has been introduced as technical improvement and ...potential alternative to total mesorectal excision (TME) in early rectal cancers and in frail patients. This study reports the perioperative and short-term oncological outcomes of r-TAMIS for local excision of early-stage rectal cancers.
Methods
Retrospective analysis of a prospectively collected r-TAMIS database (July 2021–July 2023). Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated.
Results
Twenty patients were included. Median age and body mass index were 69.5 (62.0–77.7) years and 31.0 (21.0–36.5) kg/m
2
. Male sex was prevalent (
n
= 12, 60.0%). ASA III accounted for 66.7%. Median distance from anal verge was 7.5 (5.0–11.7) cm. Median operation time was 90.0 (60.0–112.5) minutes. Blood loss was minimal. There were no conversions. Median postoperative stay was 2.0 (1.0–3.0) days. Minor and major complication rates were 25.0% and 0%, respectively. Seventeen (85.0%) patients had an adenocarcinoma whilst three patients had an adenoma. R0 rate was 90.0%. Most tumours were pT1 (55.0%), followed by pT2 (25.0%). One patient (5.0%) had a pT3 tumour. Specimen and tumour maximal median diameter were 51.0 (41.0–62.0) mm and 21.5 (17.2–42.0) mm, respectively. Median specimen area was 193.1 (134.3–323.3) cm
2
. Median follow-up was 15.5 (10.0–24.0) months. One patient developed local recurrence (5.0%).
Conclusions
r-TAMIS, with strict postoperative surveillance, is a safe and feasible approach for local excision of early rectal cancer and may have a role in surgically unfit and elderly patients who refuse or cannot undergo TME surgery. Future prospective multicentre large-scale studies are needed to report the long-term oncological outcomes.
Robotic Low Anterior Resection Mykoniatis, Ioannis; Siddiqi, Najaf N; Khan, Jim S
Diseases of the colon & rectum,
02/2021, Letnik:
64, Številka:
2
Journal Article
The main advantage of the robotic approach is the surgical precision that the technology offers. It is particularly useful in rectal cancer as this is a technically challenging procedure. The ...technological advantage of the robot leads to better postoperative outcomes. Apart from the 3D vision and endowrist instrumentation in comparison to laparoscopy, the options of using fluorescence imaging, endowrist stapler, and table motion have revolutionised the way of performing an anterior resection. Thus, the true benefit of these advances will be the quality of the surgery, which leads to better postoperative outcomes. This article focuses on the current status of applications of new modalities and technology development in robotic rectal surgery. A systematic literature search was performed using PubMed, MEDLINE, and cochrane database. The studies included were considered based on the following (1) articles written in English, (2) full text is available, (3) whether the topic is related to the use of novel technologies during robotic rectal surgery, and (4) sample: adult patients and malignant rectal disease. The primary end point was to analyse the current use of technological advances in robotic rectal surgery. Only a few studies are currently available on the use of these different technologies in robotic colorectal surgery. Many of these reports describe promising results, although with short-term outcomes. The use of technologies in robotic colorectal surgery is safe and feasible and can be used together to improve short-term outcomes. Intraoperative fluorescence angiography has demonstrated to reduce the rate of anastomotic leak, whereas the robotic stapler and the table motion simplify anatomic resection.
To compare short-term postoperative outcomes in patients undergoing robotic total mesorectal excision (TME) after the use of robotic and laparoscopic staplers. Over a 5-year period, 196 patients were ...divided into 2 groups according to the use of laparoscopic (LS) or robotic stapler (RS). Patient demographics and postoperative complications were compared. A total of 145 (74%) robotic TME were performed using the LS and 51 (26%) the RS. No conversions to laparoscopy or laparotomy were observed, in either group. Transection of the rectum using one or two firings was achieved in a higher proportion of RS cases (91%) compared with LS cases (60%;
p
< 0.001). The anastomotic leakage (AL) rate was 4% in the RS group vs. 7% in the LS group (
p
> 0.05). However, when three or more firings were needed for the rectal transection, the risk of AL increased (3.4% with ≤ 2 firings vs. 10.7% with ≥ 3 firings,
p
= 0.006). Our data confirm that multiple stapler firings for rectal transection have a major impact on AL. The robotic stapler simplifies the transaction, so that rectal division requires fewer stapler firings, with a potential reduction in the incidence of AL.
Around 20% of rectal tumors are locally advanced with invasion into adjacent structures at presentation. These may require surgical resections beyond boundaries of total mesorectal excision (bTME) ...for radicality. Robotic bTME is under investigation. This study reports perioperative and oncological outcomes of robotic bTME for locally advanced rectal cancers.
A multicentre, retrospective analysis of prospectively collected robotic bTME resections (July 2015–November 2020). Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated.
One-hundred-sixty-eight patients (eight centres) were included. Median age and BMI were 60.0 (50.0–68.7) years and 24.0 (24.4–27.7) kg/m2. Female sex was prevalent (n = 95, 56.8%). Fifty patients (29.6%) were ASA III-IV. Neoadjuvant chemoradiotherapy was given to 125 (74.4%) patients. Median operative time was 314.0 (260.0–450.0) minutes. Median estimated blood loss was 150.0 (27.5–500.0) ml. Conversion to laparotomy was seen in 4.8%. Postoperative complications occurred in 77 (45.8%) patients; 27.3% and 3.9% were Clavien-Dindo III and IV, respectively. Thirty-day mortality was 1.2% (n = 2). R0 rate was 92.9%. Adjuvant chemotherapy was offered to 72 (42.9%) patients. Median follow-up was 34.0 (10.0–65.7) months. Distant and local recurrences were seen in 35 (20.8%) and 15 patients (8.9%), respectively. Overall survival (OS) at 1, 3, and 5-years was 91.7, 82.1, and 76.8%. Disease-free survival (DFS) at 1, 3, and 5-years was 84.0, 74.5, and 69.2%.
Robotic bTME is technically safe with relatively low conversion rate, good OS, and acceptable DFS in the hands of experienced surgeons in high volume centres. In selected cases robotic approach allows for high R0 rates during bTME.
•20% of rectal tumors are locally advanced invading adjacent structures at diagnosis.•Robotic beyond TME is under investigation.•Robotic beyond TME is technically safe with relatively low conversion rate.•Robotic beyond TME provides good overall and acceptable disease-free survival.•In selected cases, robotic beyond TME provides high R0 rates.
IntroductionThe surgical treatment for locally advanced or recurrent rectal cancer requires oncological clearance with a pelvic exenteration or a beyond total mesorectal excision (TME). The aim of ...this systematic review is to explore the safety and feasibility of robotic surgery in locally advanced and recurrent rectal cancer by evaluating perioperative outcomes, oncological clearance rates, and survival and recurrence rates postrobotic beyond TME surgery.MethodsThe systematic review will include studies published until the end of December 2023. The MEDLINE, EMBASE and Scopus databases will be searched. The screening process, study selection, data extraction, quality assessment and analysis will be performed by two independent reviewers. Discrepancies will be resolved by consensus with a third independent reviewer. The risk of bias will be assessed with validated scores. The primary outcomes will be oncological clearance, overall and disease-free survival, and local and systemic recurrence rates post robotic or robot-assisted beyond TME surgery for locally advanced or recurrent rectal cancer. Secondary outcomes will include perioperative outcomes.Ethics and disseminationNo ethical approval is required for this systematic review as no individual patient cases are studied requiring access to individual medical records. The results of the systematic review will be disseminated with conference presentations and peer-reviewed paper publications.PROSPERO registration of the studyCRD42023408098.
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